Medical Academia weighs in on the “opiate epidemic” and the FDA

Friday Feedback: Should Opioids Be FDA’s Top Priority?

Experts review agency’s actions thus far & offer additional strategies

https://www.medpagetoday.com/painmanagement/painmanagement/65433

During the new FDA Commissioner Scott Gottlieb’s first all-hands address to agency staff, he declared the opioid abuse epidemic as the agency’s “greatest immediate challenge.”

As opioid abuse and overdose deaths continue to rise, it’s clear that the crisis should be a public health priority. However, the jury is still out on what efforts the FDA can and should take to increase awareness and better manage the issue.

Do you agree that combatting opioid abuse should be the agency’s top priority? If not, what would you pick?

Petros Levounis, MD, Rutgers University: Yes, wholeheartedly! We are seeing a devastating increase in fentanyl and heroin use in our communities with increased rates of admissions and deaths.

Dessa Bergen-Cico, PhD, Syracuse University: I agree that combatting opioid abuse, specifically prescription opioid abuse and overprescribing, should be a top priority of the FDA.

Peter R. Martin, MD, Vanderbilt University: I do not believe the FDA can do anything truly transformative to combat this problem. Where the FDA may help is in facilitation of the development of medications for psychiatric disorders, including opioid and other drug use disorders. Although there have been some advances in medication assisted treatment of opioid and other drug use disorders, these advances have received little priority for the pharmaceutical industry for a variety of reasons, including stigma associated with drug use disorders (“addiction”) and lack of financial incentives to pharmaceutical companies.

Timothy A. Collins, MD, Duke University: No. Combating opioid abuse should be a priority, but not the top priority for the FDA. The FDA’s top priority should be combating the needless increase in the cost of prescription medications.

Sally Satel, MD, American Enterprise Institute: Yes. With no infectious epidemics raging and the death toll from opioids rising, it is a top priority. But I would put easing regulations for electronic cigarettes as a close second.

Jason M. Hockenberry, PhD, Emory University: To the extent it fits in the FDA purview, yes. This means FDA should really focus on the pipeline issues in pharmaceutical and device development related to the treatment of opioids, and pain management related treatments more broadly. The bigger immediate issues in the opioid epidemic are the purview of the DEA, CDC Center for Injury Prevention, SAMHSA, CMS, and the broader healthcare system, not FDA.

Lewis Nelson, MD, Rutgers University: No other FDA related issue is associated with the scope of consequences as is occurring with the opioid epidemic, but it is not just abuse. More important are complications of long-term use due to addiction, dependence, and hyperalgesia (worsening pain due to opioids), as well as overdose death. Therefore, this very realistically should be priority number one.

What can the FDA actually do about opioid abuse that it isn’t already doing?

Joseph A. Boscarino, PhD, MPH, Geisinger Clinic: I’d say find a means to support more applied health system-level research among providers. This knowledge will help in development of more effective interventions at the healthcare delivery site.

 

Satel: Put special focus on development of non-addicting analgesics.

Levounis: The FDA has done a lot for the epidemic already, but further facilitating and promoting treatment of opioid use disorder with safe and effective medications, such as buprenorphine, is greatly needed.

Amol Patwardhan, MD, PhD, University of Arizona: Better education for primary providers and better public education campaigns.

Bergen-Cico: Require and mandate adequate training and education in addictions for healthcare professionals. It is not required and it is a major factor of what healthcare staff deal with in on a daily basis. Regulate advertising and direct marketing of prescription medications to consumers and revise practices of pharmaceutical reps being the main conduit of information for medications to doctors and nurse practitioners.

Collins: The FDA could require end-to-end tracking of every opioid medication. The ability to track from the manufacturer plant to the distribution center, then to pharmacy and patient pick-up, would significantly decrease the diversion of opioids to the illicit market. They can limit marketing of opioid products, require additional studies of longer duration for newly developed opioids, and potentially remove products from the market (if there is evidence of a safety issue).

Nelson: Overhauling the assessment of value — meaning the interplay of efficacy, safety, and cost, for all FDA regulated products would likely find that there is little basis for the ongoing approval and lax regulation of opioids for chronic pain. The FDA does not, however, currently take cost into account, and they occasionally lose sight of the risk/benefit relationship for a drug due to external forces, particularly legislative realities, pharmaceutical industry efforts, and vocal advocacy groups (which often have misaligned incentives).

What effects, if any, have you seen from previous efforts by the FDA and CDC to combat opioid overuse and abuse?

Patwardhan: Very positive outcomes. Significant improvement in patients’ and physicians’ attitudes toward chronic narcotic therapy.

Collins: The previous efforts of the CDC (and to a lesser extent the FDA) have resulted in a much greater awareness of the problems with opioids, and increased discussion between patients and their provider regarding doses and need for opioid medications. Unfortunately, this does not appear to have altered the abuse or diversion of opioids, and does not yet appear to have decreased the rate of overdose and death from prescription opioids.

Martin: The CDC has done an incredible service by bringing the opioid use “epidemic” to the attention of most Americans through seminal publications that have identified the scope and cost of this problem. Unfortunately, the policy response to this crisis immediately led to a focus by the FDA on altering pharmaceutical formulations of opioids to make them less liable to abuse. In retrospect, this response seems overly simplistic and without true understanding of drug use disorders because limiting availability of abusable opioids has simply enhanced transition of the using population to illicit drugs like heroin that are now readily available throughout the country and expanding the epidemic.

Levounis: We have an increase in regulatory oversight of opioid prescribing with good results. Prescription monitoring programs and opioid labeling changes have already given us significant results. Making naloxone easily available to users has also helped decrease the lethality of the illness.

Hockenberry: CDC has helped coordinate efforts to implement public health policies, such as prescription drug monitoring programs and pain clinic laws, that are reducing opioid prescribing, and translating into lower rates of overdose deaths. More needs to be done to get those with opioid use disorders into treatment, and these issues involve financing and other issues outside of FDA and CDC purview.

Boscarino: Addiction use disorders are complex and multifactorial. The FDA and the CDC have worked within their regulatory limitations to address these issues. I think they have had an some impact, but as we see the list of casualties grow in our local towns and cities, most wish to see more done to prevent this epidemic.

Nelson: There has certainly been a greater recognition of the extent and complexity of the use of opioids to treat pain. Some of the good and necessary efforts, such as abuse deterrent formulations, are simply nibbling at the edges of the epidemic, while others, such as public access to naloxone, are akin to closing the barn door after the horse has escaped. What we need to see is primary prevention of the short- and long-term consequences of opioid use, which will require further shifting patients’, physicians’, and regulators’ understanding and expectations about the value of opioid use for pain.

Satel: The abuse deterrent re-formulation of OxyContin has been disappointing. Some users have shifted to heroin/fentanyl and others just use immediate-release generics. The substitution dynamic makes the problem very difficult.

IOWA: < 50% of hospitals get ABOVE AVERAGE GRADE on Pt Safety and ERRORS

Iowa hospitals get grades from nonprofit group for safety, injuries

http://siouxcityjournal.com/lifestyles/health-med-fit/iowa-hospitals-get-grades-from-nonprofit-group-for-safety-injuries/article_500b4f97-750c-5797-99bc-411bc0ab3366.html

SIOUX CITY | Sioux City’s two hospitals scored average grades for patient safety from a national nonprofit organization that calls attention to deaths and injuries that result from medical errors. 

UnityPoint Health — St. Luke’s Spring 2017 Leapfrog Hospital Safety Grade remained unchanged from 2014, when the hospital moved up from a “D” to a “C.” Mercy Medical Center, which earned an “A” in the spring of 2014, fell to a “B” later that fall. In the spring of 2016, the hospital dropped another letter grade to a “C,” which it has maintained.

Of the 31 hospitals in Iowa that were graded, 11 received “A’s,” six got “B’s” and 12 were given “C’s.” Two hospitals received a “D,” the lowest grade handed out in the state. Those hospitals were Mercy Medical Center of Des Moines and Mercy Medical Center — West Lakes in West Des Moines.

The three Siouxland hospitals to receive “A’s” were Avera Sacred Heart Hospital in Yankton, South Dakota; Lakes Regional Healthcare in Spirit Lake, Iowa; and Spencer Hospital in Spencer, Iowa.

“Our providers actively put patients and their safety at the heart of every decision, and care is always coordinated between clinics, hospitals or homes,” Mike Kafka, medical director of quality and safety for St. Luke’s, said in response to the hospital’s grade. “Our teams continuously prioritize best practices throughout the system to sustainably manage resources and ensure the best outcome for every patient at every time.”

In a statement, Dave Smetter, Mercy Medical Center — Sioux City’s vice president of communications and community development, said the hospital is committed to delivering innovative, safe and quality health care to every patient.

“To maintain our performance and focus, Mercy voluntarily seeks out some of the most rigorous certifications and accreditations available,” he said. “The findings of these reviews show a consistent conclusion — Mercy is a high performing organization in terms of quality and safety.”

The Leapfrog Group hands out letter grades from A to F to more than 2,500 U.S. general hospitals based on infections, injuries and medical and medication errors that are publicly reported.

Iowa ranked 22nd in the nation based on its percentage of “A” hospitals (35.5 percent). Maine earned the No. 1 spot with 68.8 percent of its hospitals receiving “A’s.” North Dakota, Alaska, Delaware and the District of Columbia tied for 47th place. No hospitals in those states received an “A” grade.

The Leapfrog Group says the choice of a hospital could be a life-or-death decision as hospitals vary greatly based on infection rates, surgical errors and patient injuries.

Mercy Medical Center — Sioux City recorded a zero, the best possible outcome, for preventing Methicillin-resistant Staphylococcus aureus infection, a type of staph bacteria that can cause life-threatening bloodstream infections, pneumonia and surgical site infections.

Mercy’s scores were worse than the average hospital’s scores for infection in the blood during an intensive care unit stay, infection in the urinary tract during an ICU stay and for Clostridium difficile infection or C. diff — a bacterium that can cause diarrhea, abdominal pain, loss of appetite and fever.

For surgical site infections after colon surgery, Mercy’s score was 2.647. The worst hospital scored a 3.461, while the average hospital had a score of 0.899. According to the Leapfrog Group, such an infection after surgery can be very serious as it could spread throughout the body, resulting in a long ICU stay or even death.

St. Luke’s fared better than the average hospital in four of those five categories. The hospital scored worse than Mercy (1.324) and the average hospital (0.893) for C. diff infection with a 1.397. In the patient falls category, St. Luke’s received a score of 1.198. Mercy’s scored a 0.276, which was better than the average hospital’s score of 0.390. The Leapfrog Group says falls, which can cause serious injury or result in death, commonly occur in hospitals when patients who can’t walk on their own try to get out of bed.

While the Leapfrog Group recommends that health care consumers seek out the safest hospital in their area, preferably one with an “A” grade, the ranking is one of several that patients can consider when choosing a hospital. For example, the Centers for Medicare & Medicaid Services (CMS) offers an online Hospital Compare tool which gives hospitals an overall star rating. 

Although the Leapfrog Group uses national performance measures from its own hospital survey, as well as data from CMS, the American Hospital Association’s Annual Survey, the Centers for Disease Control and Prevention and other sources to generate its grades, the independent organization has come under attack by researchers.

A University of Michigan study published in March in the journal Medical Care found that more than 50 percent of hospitals that participated self-reported perfect scores for all but one Safe Practices Scores measure. Researchers concluded that Safe Practices Scores had little connection to hospital-acquired infections or whether CMS imposed penalties for excessive readmission rates and high rates of patient injuries.

Kafka said St. Luke’s doesn’t voluntarily report to Leapfrog’s Hospital Survey, but does provide data to other agencies that measure patient safety.

“Providing additional data to Leapfrog is not required to receive a safety grade, however, other independent groups have ranked St. Luke’s high in patient safety absent self-reporting,” he said.

Smetter said Mercy believes in open communication and the reporting of quality and safety results, but recognizes that “the sheer volume of ratings surveys and methodologies such as the Leapfrog Survey can lead to confusion.”

He cited a study conducted by Johns Hopkins researchers that evaluated measures for hospital safety used by common public ranking systems, including Leapfrog’s Hospital Safety Score. The study, which was published in the journal Medical Care in December 2016, found only one measure out of 21 that met scientific criteria for being considered a true indicator of hospital patient safety.

“As an acute care medical and referral center, Mercy serves many patients suffering from traumatic injuries and critical illnesses,” he said. “Despite caring for high volumes of these most critical patients, Mercy meets or exceeds quality and safety targets.”

 

At least 10 Indiana police agencies now own drones: using appears to be against the law in Indiana.


Indiana police departments want drones. There’s just one big problem.

http://www.whas11.com/news/local/indiana/indiana-police-departments-want-drones-theres-just-one-big-problem/441173901

(INDYSTAR.COM) – Indiana’s two largest police departments both want drones; one for crowd surveillance at major gatherings Downtown, the other to monitor traffic at events such as the Indiana State Fair.

There’s just one problem. Both uses appear to be against the law in Indiana.

As the cost of drones drops and police departments rush to acquire the latest technology, officers are finding it difficult to navigate a tangled web of federal and state policies. They also face ethical questions. How will the community respond to cameras in the skies? And what are the appropriate uses?

 

Across the country, more than 340 public safety agencies either have drones or the authorization to fly them, according to an April report from the Center for the Study of the Drone at Bard College. More purchases occurred last year than all previous years combined, the report found.

And when it comes to finding ways to use them, well, the sky is the limit — which has created some concerns.

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In North Dakota, police have authority to attach nondeadly weapons, such as stun guns and devices to fire rubber bullets, which drew a rebuke from the American Civil Liberties Union.

In Connecticut, the state legislature briefly considered a bill this year that would have allowed police agencies to attach deadly weapons.

But most drones are simply strapped with cameras, giving police high-definition pictures from the sky.


Indiana State Sen. Eric KochPhoto: Provided by Indiana Senate Republicans

At least 10 Indiana police agencies now own drones, and more are considering the possibility. Indianapolis Metropolitan Police Department hopes to identify funding in the 2018 budget, Chief Bryan Roach told IndyStar, to begin deploying “in a very limited scope.” Top officials at the department said crowd surveillance was one possible benefit.

Indiana State Police also are currently researching drones, a spokesman said, adding traffic control was one of the goals.

But here in Indiana — which is among 17 other states with similar laws, according to a National Conference of State Legislatures report — a police department needs a warrant to use a drone, except in a few circumstances and in emergency situations.

That means IMPD most likely wouldn’t be able to fly near large gatherings, providing a bird’s-eye view to look for wrongdoing, unless officials feared a terrorist attack or expected a crime. Nor could state police watch for traffic snarls outside big events. When told of the restrictions, both departments acknowledged they needed to conduct more research, and said they would only use drones for legitimate purposes allowed by the law.

Eric Koch, who as a state representative authored Indiana’s drone laws in 2014 and 2016, said the laws add judicial oversight, and err on the side of privacy.

“And that’s an expectation among the public,” said Koch, a Republican who’s now a state senator.

DRONE CATCHES A HIDING SUSPECT

In March, in the northeast corner of the state, Indiana saw perhaps the best example of a drone’s policing power.

There, in rural Noble County, sheriff’s deputies were hunting for a man in the dark. He had refused to pull over for a traffic stop, then crashed as he sped away, and ran into nearby cornfields, wetlands and woods.

Deputies set up a perimeter. They first hunted for the man using K-9s, but the dogs lost the scent.

Then the Noble County Sheriff’s Department’s two-man drone team launched a DJI Inspire 1 unmanned aerial vehicle with a thermal imaging camera that picks up heat signatures and relays images to a hand-held monitor. It displays a person as a bright white figure on a gray landscape.

They quickly found the suspect walking alone in a cornfield.


A FLIR integrated thermal camera is attached to a DJI Inspire 1 drone at the Noble County Sheriff Department, May 11, 2017.Photo: Michelle Pemberton/IndyStar

The craft hovered at 200 feet, chasing the man as he continued fleeing from police. The drone operators radioed other deputies, telling them to follow the drone’s lights to the man.

Soon, he was in handcuffs.

Without the drone’s aerial view, “he probably would have gotten away that night,” said Deputy Brandon Chordas, who aptly named his drone Con Air, after the 1997 Nicolas Cage movie about an aircraft transferring convicts to a prison. “We were giddy.”

In all, the mission took about 20 minutes, the deputies said.

Drones also helped the deputies locate a runaway teen in about five minutes. And they needed only 25 minutes to find the body of a man who died while hunting for mushrooms alone in the woods.

“What used to take hours now takes minutes,” Chordas said.

The department, which originally faced local criticism for buying the drones, decided to post the video of the March incident on Facebook. The reactions and comments were overwhelmingly supportive.

“One can RUN, but they can’t HIDE!!” one person wrote.

“Now THAT is a good investment in taxpayer dollars,” another wrote.

SAVING MONEY AND LIVES

Drones help officers reconstruct major crashes and provide aerial photos of sweeping crime scenes. They also can aid during SWAT situations or natural disasters.

“It’s a life-saving device,” said Jim White, a public safety senior lecturer at Indiana University–Purdue University Indianapolis and former Indiana state trooper.

The Warrick County Sheriff’s Department in southwest Indiana has used its drones about 40 times so far, Chief Deputy Michael Wilder said, mostly at crash scenes.

“As the technology advances, we’ll find more and more ways to use them,” Wilder said.

So far, the Valparaiso Police Department in Worthwest Indiana has used its drone only a few times, most recently to help another agency search for evidence following a murder. Valparaiso officers also have searched for a dementia patient who walked away, and for a suicidal person who needed help.

IMPD sees a lot of potential in a drone, said Sgt. Kendale Adams, spokesman for the department, but finding money isn’t easy. Once the everyday needs of the department are funded, he said, “we never have a whole lot of money” left for things like emerging technology.


Deputy Shafter Baker co-pilots a DJI Inspire 1 drone at the Noble County Sheriff Department, May 11, 2017. (Photo: Michelle Pemberton/IndyStar)

Drones can range from a few hundred dollars for an inexpensive model to hundreds of thousands of dollars for the most advanced, said White, whose IUPUI class recently delivered a research project on drones to state police.

The Inspire 1 appears to be the most popular drone for Indiana officers, costing about $15,000 when you include an expensive thermal imaging camera.

“It’s absolutely amazing what you can do with it as far as viewing in the dark,” said Phil Rochon, Valparaiso IT officer. His drone also has a parachute that automatically deploys if the device were to unexpectedly drop from the sky after a bird attack or a mechanical failure.

Drones can, however, offer long-term savings to a big department such as IMPD. The department expects the use of drones to cut down their reliance on an aging helicopter, which costs several hundred dollars per hour to fly.

Today’s drones couldn’t completely replace helicopters, though. Rochon noted the maximum flight time on an Inspire 1, which is limited by battery life, is 18 minutes. The drone won’t work in temperatures below 14 degrees, and winds of 22 miles per hour will ground the unit, Rochon said.

PUBLIC POLICY AND TECHNOLOGY

Many of these uses are clearly allowed under an Indiana law that was adopted after an IndyStar and USA TODAY investigation found Indiana State Police had acquired a Stringray, a tool used to collect cellphone records. Drones were wrapped into the 2014 bill.

Police may use drones for search-and-rescue efforts, to record crash scenes, and to help in emergencies, such as natural disasters or terrorist attacks.

In Indiana, though, just about every other use for police requires a warrant.

The purpose of Indiana’s law was to protect people from unreasonable searches that might not have been anticipated when the Fourth Amendment was adopted to protect citizens’ privacy.

“Without that law, the Fourth Amendment doesn’t protect us as much as one might think it would,” said Shawn Boyne, a law professor at Indiana University Robert H. McKinney School of Law. “The major cases coming from the Supreme Court … generally permit aerial surveillance.”

States without a similar law, Boyne said, are forced to grapple with issues involving privacy, and how police exercise their authority to deploy drones. Would certain neighborhoods be targeted routinely? What discretion does an officer have?

Indiana’s law answers many of those questions, she said, though she noted parts of the law are still unclear. For example, what would happen if police were to use a drone illegally, without entering the images they capture into evidence in a criminal case?

“Really the drone issue comes up mainly if they try to introduce information into a criminal proceeding,” Boyne said. “And then that’s where the whole Fourth Amendment protections are triggered.”

In addition to state laws, the Federal Aviation Administration issued a set of guidelines that has resulted in a hodgepodge of practices and certification levels.

The Tippecanoe County Sheriff’s Department, for example, isn’t authorized to fly at night right now, while the Valparaiso Police Department is.

Multiple officers contacted by IndyStar said becoming certified was confusing. One called the process “extremely complicated.” Another said studying for a test was like “reading a foreign language.”

After buying a drone before most other departments, the Shelby County Sheriff’s Department decided to abandon its program a few years ago.

The reason? Too many stipulations, and too much “red tape,” Maj. Louie Koch said.

GAINING TRUST

Understanding the rules is one step for law enforcement; making sure a community trusts a police department to use a drone responsibly is another, said Jim Bueermann, president of the Washington, D.C.-based Police Foundation and a former police chief in California.

He pointed to Community Policing & Unmanned Aircraft Systems, a guidebook prepared by the Police Foundation on behalf of the U.S. Department of Justice. The report references instances of community backlash against drone programs in Seattle, San Jose, Calif., and Los Angeles in 2013 and 2014.

To begin, Bueermann said, departments should meet with local citizens to determine what uses would be considered appropriate.

“What is not acceptable in Indianapolis might be acceptable in Dallas,” he said. “Each community is going to view these things differently.”

Officers across Indiana have heard concerns from citizens, too. Some are fearful that drones will be used to peek into their homes and backyards, or to clock them speeding down the highway.

Officers interviewed by IndyStar shook off such concerns, by noting their respect for privacy.

“We’re not just going to be throwing them in the air willy-nilly, flying over people’s backyards to see if they’re growing marijuana,” Indiana State Police Capt. David Bursten said. “We’re going to have to have a warrant — as we should — and be able to articulate why we’d be flying in an area.”

Adams, the IMPD sergeant, said his department was not aware of Indiana’s warrant requirement, but would seek greater clarity before buying a drone.

“Obviously, we’d follow the law,” he said.

There may be some disagreement about that law, however. Adams noted an Indiana exception that allows officers to use drones without a warrant if there’s a “substantial likelihood of a terrorist attack.” Some gatherings Downtown, such as political marches with potential for conflict, could meet that threshold, Adams said.

Ultimately, the courts may need to clarify such uses — unless the law is updated as technology evolves.

Koch, the lawmaker who wrote Indiana’s drone laws, said he’d be willing to discuss changes with law enforcement in the future. After all, he worked to update the law in 2016 to allow officers to use drones at crash scenes, after receiving feedback from police.

But as more Indiana agencies buy drones, Koch noted that the state hasn’t seen any instances of abuse: “Maybe the bill is doing its job.”

Call IndyStar reporter Ryan Martin at (317) 444-6294. Follow him on Twitter: @ryanmartin and on Facebook.

What you get: when a bureaucrat has TWO SONS abusing Heroin ?

Indiana has strategy to fight drug abuse, but costs are yet to come

http://www.heraldbulletin.com/news/state_news/indiana-has-strategy-to-fight-drug-abuse-but-costs-are/article_77db91bd-3254-5b82-b973-4afffef1f283.html

INDIANAPOLIS — A comprehensive strategy to address the state’s drug abuse crisis was adopted Thursday, focusing on the coordination of resources and using evidence-proven treatment programs.

However, the six-page document lists no costs of implementing the strategy introduced by Jim McClelland, who was appointed by Gov. Eric Holcomb to serve as the state’s executive director for Drug Prevention, Treatment and Enforcement.

Asked to estimate a cost to implement the strategy, McClelland said, “We’re going to move as fast as we can to do as much as we can with the resources that we have and we’re going to do this the best we can to try to attract more resources.”

 

He said that guidelines were needed first in tackling the complex issue.

Emphasis is also given to expanding the approach to treatment by increasing the use of drug courts, diversion programs and by promoting “wrap-around” services ranging from housing for recovering addicts to seeking to “eliminate punitive policies that terminate services for people who relapse.”

The commitment to treatment was echoed by two Batesville brothers who went through addiction programs in California.

“I feel treatment is a much better option, if we have the resources for treatment, versus locking up everybody who has a drug problem,” Connor Ryan, 24, said.

Although programs were available for him in Indiana, he chose to go to California to go through the same program as his older brother, Sean.

“I feel it’s very difficult to get sober at someplace where you’ve used,” Connor Ryan said.

Sean Ryan said he had to go out of state to address his heroin addiction.

He said, “It means so much to me to be here and see that we are doing so much for this and finally addressing this because when I first got sober, I went to doctors, I went to the emergency room and there were no options. No one knew where I should go.”

The brothers are the sons of State Rep. Cindy Ziemke, R-Batesville, who was at the commission meeting.

Under the strategic plan, when treatment is not immediately available, Hoosiers could be connected with a counselor who stays in touch with the individual until treatment is ready. Emergency departments would have counselors to establish relationships with patients who overdose.

The recent General Assembly earmarked $5 million to combat substance abuse and enforcement.

 

In April, the state received a $10.9 million federal 21st Century CURES grant intended to combat substance abuse. Of that, $7.6 million could provide funding for between 60 to 75 inpatient beds for a year, said Kevin Moore, director of of the Division of Mental Health and Addiction. He said that amount “chips away at the iceberg.”

The policy now needs to be supported by the General Assembly, said legislators attending the commission meeting.

The plan seeks to reduce the supply of illegal drugs by targeting supply chains including interdiction efforts, reducing impaired driving and reducing pharmacy robberies.

The strategy strives to reduce the incidence of substance use disorders. To that end, the state is to encourage the use of alternative pain management treatments to avoid addictions to opioids. Hospitals will be urged to provide post-operative follow-up.

In one approach, a Medicaid waiver would have to be obtained to pay for residential treatment and recovery support mechanisms.

Paramedics would be trained to provide follow-up services for people with addictions who have been released for addiction treatment and live in under-served areas. A “hub-and-spokes” network could be created to provide an array of services in multi-county regions.

Walgreens: uncover new and innovative approaches to help improve outcomes for our patients

Walgreens presents five clinical studies tracking pharmacy’s impact on adherence

http://www.drugstorenews.com/article/walgreens-presents-five-clinical-studies-tracking-pharmacys-impact-adherence

DEERFIELD, Ill. — Walgreens will present the findings of five recently completed clinical studies at the 22nd Annual International Society for Pharmacoeconomics and Outcomes Research Annual International Meeting, May 20-24 in Boston. Clinical abstracts from the studies being presented focus primarily on Walgreens efforts to improve medication adherence and patient outcomes through various pharmacy initiatives.
 
“We’re continually seeking to uncover new and innovative approaches to help improve outcomes for our patients,” stated Chet Robson, medical director, clinical programs and quality, Walgreens. “The research we are presenting at ISPOR demonstrates the impact and effectiveness of various pharmacy programs and services and how they can serve to benefit patients and payers.”
 
The studies to be presented at ISPOR include:

  • Analysis of 90-day prescription refill at retail programs, and their impact on improving adherence to medications included in the CMS Star quality measures, demonstrating significantly greater adherence among Medicare Part D patients;
  • A study that observes adherence rates among Walgreens Medicare Part D patients for whom pharmacists initiated late-to-refill reminder calls. Greater impact is shown among patients with 90-day medication fills than on 30-day fills;
  • An exploration of factors associated with medication self-synchronization (aligning multiple medications to be refilled on the same day), in which findings reveal medication self-synchronization is associated with age, copay amount, selected maintenance medication indicators, day supply indicators and total number of prescriptions;
  • Examination of the Universal Medication Schedule as a means of standardizing prescriptions that demonstrates UMS prescribing is associated with significantly higher adherence to oral diabetic medications for older adults with low education who receive a multi-daily regimen. Walgreens collaborated with Northwestern University on this research; and
  • A study exploring length of therapy and factors associated with HIV pre-exposure prophylaxis medication adherence, demonstrating significantly higher adherence among older age groups, males, users of HIV-specialized services, and those with private insurance. The study found that patients used PrEP on average for seven to eight months in the first year.

Isn’t it amazing that Walgreens is expressing a increased interest of pts taking their chronic  medication as prescribed…  because the more prescriptions they fill.. the more money they can make ?

CMS Star quality measures That will financially PENALIZE healthcare providers if they pts that they serve are not compliant with their medication to treat chronic pain diseases… right now CMS is focused on Hypertension, Cholesterol, Diabetes.

Does this suggest that Walgreens “Good Faith Policy”  regarding the filling – OR DENYING – the filling of controlled medication prescriptions by their Pharmacist is in conflict with their concerns about pts being compliant with their medications to treat chronic conditions ?  http://www.wthr.com/article/walgreens-secret-checklist-reveals-controversial-new-policy-on-pain-pills

Does this suggest that Walgreens is primarily interested in encouraging pts being compliant with their medication(s) where Walgreens stands to MAKE MORE MONEY ?

Woman says CVS didn’t properly fill son’s seizure medication prescription

Woman says CVS didn’t properly fill son’s seizure medication prescription

http://wvrecord.com/stories/511117429-woman-says-cvs-didn-t-properly-fill-son-s-seizure-medication-prescription

CHARLESTON – A Kanawha County woman is suing CVS Pharmacy after she claims it filled her child’s prescription with the wrong dosage, causing him injuries.

 

West Virginia CVS Pharmacy; CVS Pharmacy Inc.; CVS 6306 WV; Caremark; Jane Doe Pharmacist(s); and John Doe Pharmacy Technician(s) were all named as defendants in the suit.

Cliff McLean Collins maintained a prescription for 250mg of Depakote DR through his treating physician and, as prescribed, he would ingest three pills in the morning, two in the evening and three at bedtime, according to a complaint filed in Kanawha Circuit Court.

Connie Arteese claims on or before March 31, 2015, an unbeknownst to her, Collins’ treating physician had changed his prescription and sent it to CVS and, as prescribed, Collins was to receive his medication as taking two 250mg tablets at 6 a.m., two tablets at 2 p.m., and three tablets at 10 p.m.

On April 1, 2015, Arteese traveled to CVS in St. Albans to pick up Collins’ prescription and, upon arrival, she was directed that Collins should take the drug in the manner as prescribed on the bottle, however, CVS had negligently, carelessly and recklessly mis-filled his prescription, according to the suit.

Arteese claims believing the instructions to be correct, she permitted Collins to ingest the prescription in the manner prescribed on the bottle, which, instead of totaling 1,750mg, actually totaled 3,500mg.

Following the unknown, unauthorized and dramatic increase in Collins’ ingestion of Depakote, he initially showed signs of decreased energy and strength, followed shortly thereafter by a marked increase in the number of seizures, which would vary dramatically in number each day, according to the suit.

Arteese claims on April 27, 2015, she contacted CVS to request a re-fill and was advised there were no refills due to the prior dosage change, which perplexed her and she retrieved one of the bottles of the prescription, where a closer examination revealed that the instructions and the total amount of milligrams were not consistent.

When Arteese telephoned Collins’ treating physician to inquire about the incorrect prescription, the physician requested Collins be brought to Cleveland Clinic immediately for treatment and evaluation, according to the suit.

Arteese claims the defendants failed to correctly fill the prescription.

As a direct and proximate result of the breach of standard of care, and the carelessness, recklessness and negligence of the defendants, Collins ingested the incorrect dosage and sustained physical injuries; pain and suffering; mental anguish; increased costs of care, reasonable and necessary medical expenses; and annoyance and inconvenience, according to the suit.

Arteese is seeking compensatory and punitive damages. She is being represented by Robert B. Warner and Andrew D. Byrd of Warner Law Offices.

The case is assigned to Circuit Judge James C. Stucky.

Kanawha Circuit Court case number: 17-C-589

 

 

PA fired: some of his patients were on high doses of opioids that exceeded clinic policy?

Patients Allege Mistreatment at Montana Pain Clinic

www.painnewsnetwork.org/stories/2017/5/18/patients-allege-mistreatment-at-montana-pain-clinic

By Pat Anson, Editor

A Montana pain clinic is under fire from patients for abruptly stopping their opioid medication, forcing them to take expensive drug tests, and steering them towards invasive and potentially dangerous procedures.

Some former patients at the Benefis Pain Management Center in Great Falls also allege they have been unfairly labeled as addicts, which has made it difficult for them to find new doctors.

“I’ve never been treated so badly in my life as I have at Benefis, to the point that I terminated my care with them, because I couldn’t do it. I couldn’t be called an addict and a junkie anymore,” says Tami Duncan, a 50-year old woman who suffers from chronic back pain.

“I’m not going back. I am done with them,” says another former patient. “It’s like I was a junkie just looking for my next fix. And that’s not the case at all.”

“You become terrified of who you are going to see next and what they are going to say and do to you,” said a current patient. “The fear of losing my job and not to mention my sanity. The fear that I am going to be labeled an addict if I don’t do what they tell me to.”

“They do not care. They do not know their patients. They do not review the records,” another current patient said. “There is so much more. Billing errors, rarely treated like a person, the wait to see doctors, and then 15 minutes (with them) and you are gone.”

The Benefis pain clinic is part of Benefis Health System, a non-profit community-based health organization that operates a hospital and provides a wide variety of medical services in Great Falls, a city of over 58,000 people in north central Montana. With over 250 physicians and about 3,000 other employees, Benefis is the largest employer in the area outside of government.

“We have some of the finest nurses and Physician Pain Management specialists, with experience second to none. This experience combined with their compassion, provide a tremendous supportive atmosphere. Our pain management team aims to help people reduce and cope with pain,” Benefis says on its website.

Some patients disagree, saying Benefis doctors are quick to label a patient as non-compliant, which has led to patients being discharged from the clinic. In a rural state such as Montana, where options for pain care are limited, that is not a threat to be taken lightly.

“Any questions or requests can be seen as combative. To try and protect ourselves we were recording our appointments. Somehow it was found out and there are now signs everywhere stating no recording or photos,” a patient told PNN.

“We are not allowed to have anyone come into the appointment with us. I am being bounced around to different providers. There is no stability. I am still receiving meds but at a fraction of what they were. To say that I am hurting would be an understatement.”

“Our clinic does not suddenly discontinue opioid prescriptions for patients unless we feel it is unsafe to continue prescribing them,” said Katrina Lewis, MD, a Benefis pain management specialist. “We have patients that have been on pretty high doses of opioids for many years but are not experiencing much relief from pain anymore and their quality of life is suffering significantly.  

A SIGN POSTED AT THE BENEFIS PAIN CLINIC

A SIGN POSTED AT THE BENEFIS PAIN CLINIC

“We have to do what is medically responsible and safe for our patients. Opioids are incredibly powerful drugs. Given the choice between a patient potentially dying and a patient going into withdrawal, we have to pick withdrawal.”

In an age of opioid hysteria and misleading headlines about an overdose epidemic fueled by painkillers, pain patients around the country – including many who have been stable and compliant on opioid medication for years – are seeing their doses cutback or eliminated. Some have been discharged by doctors who are leery of scrutiny by the DEA and no longer want to treat chronic pain.

What sets the disgruntled patients at Benefis apart from everyone else is that they have formed a support group for each other. And some are speaking out publicly against a provider they feel has shamed and abandoned them. For this story, PNN interviewed over a dozen current and former patients, including some who asked to remain anonymous.

Physician Assistant Fired

Many of the problems at the Benefis pain clinic can be traced back to the firing of Rodney Lutes, a popular 68-year old physician assistant (PA) who – until he was let go — was treating as many as 1,000 pain patients.  

RODNEY LUTES, PA

RODNEY LUTES, PA

“I was thunderstruck. It totally blindsided me. I thought I was doing everything I could for the patients,” says Lutes about his firing in early March.

Lutes was told he was “no longer a good fit” at the clinic and that his position was being eliminated. He believes the real reason was that some of his patients were on high doses of opioids that exceeded clinic policy.

“They didn’t come to me and say, ‘Hey Rod, you need to fall in line here and start reducing these people.’ There was no warning whatsoever,” said Lutes. “The majority of the patients were doing very well. You always have some patients who aren’t doing well and you try to adjust their medications. I had a number of those. But otherwise I felt that the patients were doing very well on the doses they were on.”

“We respect our employees’ privacy rights and consequently cannot comment on the details of Rodney Lutes employment with Benefis,” says Keri Garman, Director of Corporate Communications at Benefis.

There is no record of any disciplinary action against Lutes by Montana’s Board of Medical Examiners. He has been licensed as a PA in the state since 1991.

“He’s compassionate and understanding. I’ve never met anybody else like him in my life,” says Tami Duncan, a patient of Lutes for 20 years. “And Benefis is crucifying that man, along with his patients.”

Duncan was on relatively high doses of oxycodone and MS-Contin for chronic back pain caused by herniated and bulging discs, arthritis and fibromyalgia. She’s also had as many as 60 epidural injections, nerve blocks and other “interventional” procedures, which not only failed to stop her back pain, but may have given her adhesive arachnoiditis, a progressive and chronic inflammation of spinal nerves that she was recently diagnosed with.

“Sometimes it feels like I’m standing in a pot of hot boiling water all day,” says Duncan. The first thing she was told by her new doctor at Benefis was that he was taking her off opioids.

“He comes in and didn’t even look at my files, didn’t even look at my record. And he told me, ‘Well Mrs. Duncan, the game plan is we’re taking you off all your medications and then we’ll terminate your care.’” she recalled. “He didn’t know anything about what was wrong with me. Didn’t know I had nerve conduction tests done to show all the nerve damage I have in both of my legs. He basically came out and said, ‘All you patients all need to go into treatment. You’re addicts.’”

“There are many scenarios that may warrant discontinuation of a particular regimen for the benefit of the patient.  Opioids can have many negative side effects for patients,” said Dr. Lewis in a lengthy statement for PNN prepared by Benefis. “We understand that this can be unsettling for patients who have been with a provider for a long period of time and who are accustomed to their care plan.”

Duncan started looking for a new pain doctor and immediately ran into problems. When she visited a pain clinic in her hometown of Havre, she was turned away without an exam or review of her medical records.

“The RN proceeded to tell me that I was a junkie, those are her words, that I was an addict and the only thing that was wrong with me is that I needed to go to treatment,” she said. “I’ve called all over the state trying to find a different pain doctor. Nobody will take me. Benefis has called every doctor in the state of Montana saying not to take any of Lutes’ patients.”

Duncan cites a letter she received from Benefis, which states: “All care providers in our community have been made aware of the changes in our clinic and with what is going on with PA Lutes’ patients.”

“It is our standard practice to send a note to referring physicians within our own health system and community to let them know of changes to the providers practicing in our clinic.  The letters never indicate the reason a person is no longer with our organization,” Kathy Hill, Benefis’ Chief Operating Officer said in the statement.

“Community providers had many patients calling with concerns about whether they would be able to get in with a new provider soon enough to avoid a lapse in their medications.

“Whether or not to prescribe opioids to any patient is at the discretion of the provider. Providers were not urged either way.”

‘Nobody Will See Pain Patients’

Regardless of the reason, many former patients of Lutes are having trouble finding new doctors, a not uncommon experience in rural areas where healthcare choices are limited.

“Nobody in Great Falls will see any pain patients. I’m just sitting here in limbo doing nothing but being in pain,” said a former patient who decided to leave Benefis after her opioid medication was stopped. The doctor who replaced Lutes persuaded her to have an epidural, a decision she now regrets.  

“They’re forcing everybody to get injections,” says Adrienne Barnoski, another former patient. She and her husband Joseph, who has severe back pain, had been treated by Lutes for years.

“I’m not going to have any injections on my back after what my husband has gone through. It sometimes makes things worse,” she said.

Epidural injections have been used for decades to relieve pain during childbirth, but in recent years injections of a steroid into the epidural space around the spinal cord have increasingly been used to treat back pain.  The shots have become a common and sometimes lucrative procedure at pain clinics, where costs vary from as little as $445 to $2,000 per injection. Critics say the injections are risky, overused and often a waste of money.

“An epidural steroid injection is an invasive procedure. It has its risks. And I think a patient always has the right to decline an invasive procedure,” says Lutes. “I’ve had a couple of patients tell me (that they were told) to do epidural steroid injections and if they didn’t do the injections they were no longer going to be prescribed any medications. To me, that’s kind of like blackmail.  

“My patients are being treated very, very poorly. It’s horrible. I’ve had calls from patients or their spouses, very concerned the patient was going to commit suicide. It just scares me to death. And these were patients that were functionally doing great. And now they’re being told, sorry, we’re taking your medication away from you.”

Benefis says it does not pressure patients into having invasive procedures, but admits there could have been communication problems between doctors and their patients.

“This is not a policy or an expectation in any way. While we expect patients to be active participants in getting better, there is never a mandatory procedure,” said Nikki Phillips, BSN, Clinic Office Manager at Benefis Neurosciences. “We do our best to care for our patients and regret that this transition has been difficult for some. We realize we have opportunities to improve our communication with patients and will be working on that as a team moving forward.”

“The decision of whether or not to prescribe opioids to a patient is in no way related to their decision to have or not have other interventional procedures,” said Dr. Lewis. “Unfortunately there are some patients who come into the clinic with a preconceived notion that opioids are the answer for them, whether because of past practice within the medical community or other reasons, and overcoming that preconceived notion can be challenging.”

A major challenge for the patients who remain at Benefis is paying for their urine drug tests, which can cost as much as $1,500 and are not always covered by insurance.  For the past two years, Benefis has been working with a drug laboratory over 2,000 miles away in Georgia, one with a questionable past and a very uncertain future. More on that tomorrow.

I am not an attorney but this statement doses of opioids that exceeded clinic policy”  suggests that “cookie cutter corporate medicine” is in full effect in this so called “healthcare system”. 

This is the type of “one size fits all medicine” is where a class action lawsuit is going to first take place. When administrators and/or executives of a corporation starts basically dictating medical care in this manner.. you can be guaranteed that some/many pts will be harmed.  You cannot administratively invalidate the “bell curve” and the individualization of healthcare that every person needs and expects from the prescriber that they have trusted their quality of live and – at times – life itself to.

This sort of corporate medical policy edict would appear on face value that they are attempting to overwrite or supersede the state’s medical practice act which grants the prescriber professional discretion in treating pts.  

A SIGN POSTED AT THE BENEFIS PAIN CLINIC

In the whole medical industry  SOP is … “if it is not documented…. it NEVER happened ” so it would appear that this healthcare corporation only wants documentation based on “one point of view” and that would be from the healthcare provider’s perspective.  Which is “guided” by “clinic policy” and perhaps fear of continued employment…  as  RODNEY LUTES, PA recently found out… having to deal with… Benefis is the largest employer in the area outside of government.

I don’t think that it would be much of a push for a law firm to review their pt care policies to easily find out that the “most strict/limiting” are directed at those whose medical conditions require controlled medications and the rest of the pt care policies – if they do exist – have edicts that are more “general” in nature as to treatments and expected pt outcomes.

Since the pts covered by the former policies are covered by either the Americans with Disability Act or/and the Civil Rights Act.. and it would be quite easy to PROVE discrimination… which is a CIVIL RIGHTS violation under those laws.

Death linked to CVS robbery, police say

Death linked to CVS robbery, police say

http://www.duluthnewstribune.com/news/crime/4269129-death-linked-cvs-robbery-police-say

The suspect in the robbery of a pharmacy earlier this week has died, Duluth police reported.

Police said they responded to a residence in the 600 block of North First Avenue East shortly after 1 p.m. on Tuesday to the report of a dead body. Investigators responded because of the deceased individual’s age and lack of medical history, they said.

At the scene, investigators noticed numerous items that appeared to have been stolen from the CVS pharmacy at 1215 E. Superior St. on Monday. They concluded that the deceased individual was the suspect in the robbery and said they were seeking no other suspects.

The death did not appear to be suspicious, police said.

The body was taken to Midwest Medical Examiners for an autopsy and results on toxicology are being awaited to determine the manner and cause of death, police said.

The dead individual’s name was not immediately released.

Since Pharmacies in general and chains in particular have been reluctant to created a more “fortified” Rx dept… so that Rx dept robberies would become more difficult, if not impossible.

Should  these pharmacies that have left their Rx dept “wide open” and more “inviting” to robbers… be charged with some sort of violation of being complicit with what goes wrong and/or people harmed because of this reluctance/failure ?

In this particular case, should CVS and their executives be charged in contributing to the death of this person?  I can assure you that if this person had gotten a prescription from a prescriber and OD’d… the DEA would be after the prescriber… Shouldn’t pharmacies be held to the same standard ?  Shouldn’t the Boards of Pharmacy take a more proactive stance in the how Rx depts are configured and be “less robber friendly “?  The Boards of Pharmacy primary charge is to protect the health/safety of the general public.  Since the majority of the Boards of Pharmacy are “stacked” with non-practicing corporate Pharmacists… working for the same pharmacy chains that are keeping their Rx depts “robber friendly”.  In general, are the Boards of Pharmacy being negligence ?

SPEAK UP OR BEND OVER !

Congress made all these contracts for themselves. Serving in Congress is an honor, not a career. The Founding Fathers envisioned citizen legislators, so ours should serve their term(s), then go home and go back to work.

TRUMP, in a recent interview with CNBC, offers one of the best quotes about the debt ceiling: “I could end the deficit in five minutes,” he told CNBC. “You just pass a law that says that anytime there is a deficit of more than 3% of GDP, all sitting members of Congress are ineligible for re-election”.

The 26th Amendment ( granting the right to vote for 18 year-olds ) took only three months and eight days to be ratified! Why? Simple! The people demanded it. That was in 1971 – before computers, e-mail, cell phones, etc.

Of the 27 amendments to the Constitution, seven (7) took one (1) year or less to become the law of the land – all because of public pressure.

Trump is asking each addressee to forward this email to a minimum of twenty people on their address list; in turn ask each of those to do likewise.

In three days, most people in The United States of America will have the message. This is one idea that really should be passed around.
If each person contacts a minimum of twenty people, then it will only take three days for most people in the U.S. to receive the message. It’s time!

Sen. Chuck Grassley: IS DEA agents.. exaggerated their record of drug seizures “in order to obtain funding from Congress.”

Leading Republican Senator Demands To Know If The DEA Lies To Congress

https://www.buzzfeed.com/danielwagner/leading-republican-senator-demands-to-know-if-the-dea-lies

 

BE SURE TO READ LETTER 

https://www.documentcloud.org/documents/3723725-Grassley-to-DEA-OIG.html

A top Republican senator has demanded that the Drug Enforcement Administration respond to allegations that agents exaggerated their record of drug seizures “in order to obtain funding from Congress.”

Sen. Chuck Grassley, who chairs the powerful committee that oversees the DEA and Department of Justice, raised the issue in a letter sent last week to Chuck Rosenberg, the DEA’s acting administrator, and to Justice Department Inspector General Michael Horowitz. It cites a BuzzFeed News report from earlier this month, about a DEA agent stationed in Sao Paulo, Brazil, who asked his girlfriend, Larissa Carvalho, to translate sensitive DEA memos. After she ended the relationship with him, the agent, Scott Nickerson, stalked and harassed Carvalho and her friends and relatives, BuzzFeed News reported.

The harassment continued for months despite numerous official complaints by Carvalho and others, Grassley noted in the letter. She received little response from either agency, it said.

In response to BuzzFeed News’s investigation, the DEA said it initiated an investigation into Nickerson’s conduct in June 2016, “but Nickerson is still employed by DEA and reportedly has remained free to continue to harass and threaten Carvalho and her friends and family throughout the course of that investigation,” Grassley noted in his letter.

Carvalho reported the questionable drug seizure reports to the Senate Judiciary Committee, which Grassley chairs, his letter said. In a WhatsApp conversation with Carvalho dated May 2014, Nickerson appears to describe how agents stationed in Brazil lied to Washington, falsely taking credit for drug seizures by local authorities in order to help justify the field office’s funding. DEA ”receives money by telling congress how much money and dope we seize,” he wrote. “In the US, everything is pretty accurate. here, however, the office in Brazil takes credit for everything the Brazilians do, even if they had nothing to do with it.”

Agents sometimes “will take newspaper articles and report it like dea assisted with the seizure,” Nickerson added. He called the actions “an insult to the agents that are busting their ass in the States, and I don’t want to do it.” He said that if he reported these actions to senior officials, that could influence the agency’s decisions about where to station agents when they returned to the US.

Spokespeople for the DEA did not respond to requests for comment, nor did Nickerson’s attorney. A spokesperson for the Office of the Inspector General declined to comment.

Nickerson, a married agent 10 years older than Carvalho, met her in 2014 and soon began dating her, BuzzFeed News first reported on May 5. He sent her at least five documents detailing the operations and associates of drug kingpins, including their phone numbers and mobile PINs. Strict rules govern the way details like that are handled, to protect the integrity of an investigation as well as the safety of innocent people. Passing sensitive documents to people who are not meant to see them violates DEA rules and can be grounds for firing; it is not clear whether Nickerson’s actions were unlawful. After BuzzFeed’s report, one of the memos was posted in full on Twitter by an anonymous account. Images of some of documents also appeared on an online message board.

Nickerson’s written communications with Carvalho include numerous references to additional misconduct by him and other agents, as Grassley laid out in his letter. He said he hired sex workers, which is a fireable offense for DEA agents; he said the tinted windows on his government-issued SUV were useful “for safety and blow jobs”; and he used government funds to help pay for travel with Carvalho — a practice he jokingly called “Obama pays.”

After Carvalho broke up with him in late 2015, Nickerson began a campaign of stalking and harassing her, her friends, and family that continued until earlier this month, BuzzFeed News reported.

Sen. Grassley’s letter concludes with 13 questions for the DEA and the Office of the Inspector General, an independent watchdog within the Department of Justice. They include what the agencies knew about about Nickerson, when they learned it, and what they did about it. It asks the DEA when it began investigating him and which allegations it focused on, whether Nickerson has been disciplined or stripped of his security clearance, what steps the agency has taken to prevent Nickerson’s stalking and harassment, and whether DEA has looked into other agents’ misreporting of drug busts in the manner Nickerson described.

Grassley also asked the Office of the Inspector General when it became aware of allegations against Nickerson, when it first acted, and whether it recommended any actions to DEA in response to the allegations.

The Office of the Inspector General has repeatedly criticized DEA for failing to adequately supervise agents working overseas, for rampant sexual misconduct including soliciting sex workers, and for failing to discipline employees after their misconduct is exposed.